Active NPI
Paul R Summerside, MD
- Emergency Medicine Physician
- Green Bay, WI
National Provider Identifier
1720009459
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Emergency Medicine Physician
- License
- 29836
- Practice address
- 2253 W Mason St
Green Bay, WI 54303-4706 - Phone
- (920) 327-7250
- Fax
- (920) 327-7249
- NPI assigned
- Jul 21, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Emergency Medicine Physician | 207P00000X | 29836 | WI | Primary |
Addresses
Primary practice location
2253 W Mason St
Green Bay, WI 54303-4706
Mailing address
614 Randall Ave
De Pere, WI 54115-2640
Phone (920) 327-7250
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 31449300 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 29836 | WI | MD | Emergency Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1153440000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1454976000000",
"number": "1720009459",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "614 RANDALL AVE",
"city": "DE PERE",
"state": "WI",
"postal_code": "541152640",
"telephone_number": "920-327-7250",
"fax_number": "920-327-7249"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2253 W MASON ST",
"city": "GREEN BAY",
"state": "WI",
"postal_code": "543034706",
"telephone_number": "920-327-7250",
"fax_number": "920-327-7249"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SUMMERSIDE",
"first_name": "PAUL",
"middle_name": "R",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-07-21",
"last_updated": "2016-02-09",
"status": "A"
},
"taxonomies": [
{
"code": "207P00000X",
"taxonomy_group": "",
"desc": "Emergency Medicine",
"state": "WI",
"license": "29836",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "31449300",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Green Bay, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 9, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.